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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604487
Report Date: 02/10/2025
Date Signed: 02/10/2025 09:35:48 PM

Document Has Been Signed on 02/10/2025 09:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SPARKS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374604487
ADMINISTRATOR/
DIRECTOR:		SPARKS, ELSIEFACILITY TYPE:
735
ADDRESS:1973 LIEDER DR.TELEPHONE:
(619) 869-1856
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY: 4CENSUS: 3DATE:
02/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:45 PM
MET WITH:Caregiver, Harold DavidTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a case management visit after
completing a complaint visit. LPA identified herself and was granted entry by Caregiver, Harold David to whom she disclosed the purpose of the visit.

During the case management visit LPA Garcia-Centeno discussed reporting requirements with Caregiver, Harold David. There was an incident involving a client that was not reported to CCL as required. The incident will be reported to CCL and staff agreed to submit the incident report to CCL as soon as possible.

No violations were cited during today's visit.

An exit interview was conducted with Caregiver, Harold David, A copy of the report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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